Nasal decongestants would be contraindicated for which client

Discussion #1

Mr. JD is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a "normal cold" and it will not go away. He has a productive cough for green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise healthy, with no known allergies. In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, pharynx is erythematous with no exudate; there is greenish postnasal drainage; turbinates are swollen and red; frontal sinus tenderness; no cervical adenopathy, and lungs are clear bilaterally.

Is there any additional subjective or objective information you need for this client? Explain. Additional subjective information I would collect includes whether there is facial pain while bending over, headache, halitosis, or toothache which are characteristics of acute bacterial sinus infection in combination with the previously reported symptoms (Caspersen, Walter, Walsh, Rosenfeld, & Piccirillo, 2015). I would also inquire information regarding occupational/environmental exposures and whether he has ever had these symptoms before.

Would you treat Mr. JDs cold? Why or why not? I would opt for “watchful waiting” for 7 days, and not prescribe antibiotics immediately. Acute bacterial sinus infections typically can resolve on their own (Rosenfeld, 2016), and reduces the likelihood of antibiotic resistance and/or side effects of the medication.

What would you prescribe and for how many days? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings. Would this treatment vary if Mr. JD was a 10 year-old 78 lb child? Amoxicillin clavulanate 500/125 mg orally every 8 hours or 875/125 mg orally every 12 hours should be initiated as a first-line therapy for 5 to 7 days (Chow, Benninger, Brook, Brozek, Goldstein, Hicks, Pankey…File, 2012). Amoxicillin is penicillin-like class of antibiotic, that works by stopping the growth of bacteria. Clavulanic acid is a beta-lactamase inhibitor that prevents bacteria from destroying amoxicillin (MedlinePlus, 2019). Amoxicillin clavulanate (Augmentin) is administered orally by tablet, chewable tablets, or by suspension (MedlinePlus, 2019). More than half of the amoxicillin and approximately 25% to 40% of the clavulanic acid are excreted unchanged in urine (U.S. National Library of Medicine, 2019). Half-lives of amoxicillin and clavulanic acid are roughly 1.3 hours and 1 hour, respectively in otherwise healthy adults that have normal renal function (U.S. National Library of Medicine, 2019). Contraindications for Augmentin include history of hypersensitivity to amoxicillin, clavulanate or to beta-lactam drugs such as penicillin, and/or in patients with a history of cholestatic jaundice/hepatic dysfunction that is associated with Augmentin (U.S. National Library of Medicine, 2019). The dosage for Augmentin would change for a pediatric patient. The dosage for a child weighing 40 kg or more is up to 1750mg/day of amoxicillin and up to 4000 mg/day of the XR tablets (U.S. National Library of Medicine, 2019).

What health maintenance or preventive education is important for this client based on your choice medication/treatment? There are several health maintenance topics and preventative education points to address with the patient. The patient should be educated on symptoms that patient should promptly report such as allergic reaction, headache with stiff neck or difficulty turning head (Mayo Clinic, 2019). Additionally, the patient should be instructed on side effects of medication which include nausea, diarrhea, tooth discoloration, and indigestion (Mayo Clinic, 2019). Finally, the patient should be educated on prevention which include good hand hygiene, avoiding ill contacts, using a humidifier, and avoiding air pollution.

Discussion #2

Mr. JD is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a "normal cold" and it will not go away. He has a productive cough for green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise healthy, with no known allergies.

In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, pharynx is erythematous with no exudate; there is greenish postnasal drainage; turbinates are swollen and red; frontal sinus tenderness; no cervical adenopathy, and lungs are clear bilaterally.

1. Is there any additional subjective or objective information you need for this client? Explain. The additional subjective information should include, his past and present medical history. This should be comprehensive. Such as, any history of asthma, emphysema, chronic or acute bronchitis and cardiac issues to name a few. His history of current medications should be discussed. Also has JD had any wheezing, SOB or chest pain associated with his “normal cold”? It’s important to determine if he has taking any medications to help with symptoms. A current set of vital signs should be obtained.

2. Would you treat Mr. JD’s cold? Why or why not? Yes I would treat Mr. JD. Cold symptoms typically peak after three to five days and then improve over the next week. A sinus infection can stick around longer. A runny nose, stuffy nose or sinus pressure that lasts for more than 10 days, suspect an infection. Yellow or green mucous is indicative of a sinus infection (Woodard, 2016, p. 1).

3. What would you prescribe and for how many days? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings. According to research, Amoxicillin 500 mg q8h for 10–14 days or until 7 days after symptom-free (may need 21 day of treatment) is the first choice for non-penicillin allergic patients (Woo & Robinson, 2016, p. 1257). Amoxicillin has similar bactericidal action as penicillin. It acts on susceptible bacteria during multiplication stage by inhibiting cell wall mucopeptide biosynthesis. The superior bioavailability and stability to gastric acid and has broader spectrum of activity than penicillin. This medication is metabolize in the liver and excreted through urine. The half-life of Amoxicillin in adults is 0.7-1.4 hr ("Medscape," 2019, p. 1). Black box warnings consist of, anaphylactic/hypersensitivity and super infection from prolonged use. Such as, fungal or bacterial infections and C. difficile-associated diarrhea to name a few ("UpToDate," 2019, p. 15).

4. Would this treatment vary if Mr. JD was a 10 year-old 78 lb child? Include the class of the medication, mechanism of action, dosing, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings Children and infants older than 3 months of age weighing less than 40 kg, dosing is based on body weight. The usual dose is 20 to 40 milligrams per kilogram (kg) of body weight per day, divided and given every 8 hours, or 25 to 45 mg per kg of body weight per day, divided and given every 12 hours ("Medscape," 2019, p. 5). The class of drug is penicillin (Amoxicillin) is the first choice for non-penicillin allergic patients including children. Amoxicillin similar bactericidal action as penicillin. It acts on susceptible bacteria during multiplication stage by inhibiting cell wall mucopeptide biosynthesis. The superior bioavailability and stability to gastric acid and has broader spectrum of activity than penicillin. This medication is metabolize in the liver and excreted through urine. The half-life of Amoxicillin in children is 61.3 mins. The black warnings consist of Amoxicillin rash occurs in 5% to 10% of children receiving amoxicillin. Infectious mononucleosis, acute lymphocytic leukemia, or cytomegalovirus infection increases risk for amoxicillin-induced maculopapular rash. Amoxicillin-class antibiotics are not recommended in these patients ("UpToDate," 2019, p. 15).

5. What health maintenance or preventive education is important for this client based on your choice medication/treatment? Nonprescription management includes decongestants, either topical or systemic, to improve nasal obstruction. Mr. JD should be warned against long-term use of topical decongestants, but they can be very helpful in providing symptomatic relief during the few days it takes to respond to antibiotics. Saline nasal spray or wash prevents crusting of secretions in the nasal cavity, facilitating removal of secretions. Increase fluid intake to help liquefy secretions. The facial pain and headache associated with sinusitis can be severe, and the patient should be encouraged to take acetaminophen or ibuprofen for pain. A warm pack to the frontal and maxillary sinuses often provides pain relief, humidifier air at night, can alleviate the dry mouth caused by mouth breathing during sleep. Breathing in hot steam often helps clear nasal passages, but caution patients about burns (Woo & Robinson, 2016, p. 1258).